Non-surgical correction of diplopia after stroke- a strong impact factor on quality of life-minireview 1,2 2 3 NICULA Cristina , NICULA Dorin , BULBOACĂ Adriana Elena Corresponding author: Cristina NICULA, E-mail: [email protected] Balneo Research Journal DOI: http://dx.doi.org/10.12680/balneo.2019.286 Vol.10, No.4, December 2019 p: 489–494 1. Department of Ophthalmology, “Iuliu Hatieganu”University of Medicine and Pharmacy”, Cluj- Napoca, Romania 2 Oculens Clinic, Cluj-Napoca, Romania 3 Department of Pathophysiology, “Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj- Napoca, Romania Abstract One of the most frequent disorders accompanied by diplopia is represented by stroke. Beyond different symptoms of stroke, diplopia constitutes an important clinical factor in influencing the quality of life in surviving patients. In this paper we discuss the visual impairment associated with stroke location, types of diplopia, the clinical examination, and the nonsurgical treatment of diplopia. The purpose of diplopia treatment is to restore binocular vision and eliminate the double vision. The most used nonsurgical treatment for diplopia is the optical correction by the prisms. Another therapeutic option is the botulinum toxin injections. Key words: diplopia, stroke, visual rehabilitation, prism correction, Introduction Stroke represents the second leading cause of death Types of diplopia (1). Commonly defined, there are two types of Diplopia can be monocular (when the double image stroke, either ischemic (in 85% of cases) or is recognized only by the tested eye) or binocular hemorrhagic (in 15%) (1). According with the (when the double image is present when both eyes implied territory stroke is accompanied by specific are open). The vertical diplopia means that one clinical symptoms, which interfere with patient’s image is higher than the other and in orizontal quality of life (2,3).Common symptoms of stroke in diplopia the two images are separated horizontally. the left hemisphere include aphasia, right hemiparesis and right hemianopia, and in the right Causes of binocular diplopia hemisphere, left hemispatial neglect, left Binocular diplopia is the most frequent form (89%) hemiparesis and left hemianopia (4). Posterior due to different pathologies including the central circulation or infratentorial stroke comprise a lot of nervous system such as: stroke (ischemic and additional symptoms, including diplopia, bulbar haemoragic), multiple sclerosis, myasthenia gravis, palsies, dysphagia, unilateral dysmetria and cerebral tumors, neuromuscular junction incoordination, as well as reduced levels of dysfunction, palsies of the third, fourth or sixth consciousness. Diplopia appears either in right or cranial nerves or other diseases like thyroid left-sided strokes (5). ophthalmopathy and diabetes mellitus (7).When one Diplopia or double vision is one of the most eye is closed double vision disappears (8,9,10). unpleasant symptoms for the patient withstroke. Diplopia can appear as a result of different cranial Double vision represents the perception of two nerve palsy (III,IV and VI-th)or from skew deviation images of a single object seen adjacent to each other (11,12) Rowe et al. (13) in a prospective multicenter (horizontally, vertically, or obliquely) or observational case cohort study revealed that 16.5% overlapping. Sometimes the patients use the term of of patients with stroke developed ocular “ghost image”(6])revealed that 92% of patients who misalignment associated with diplopia. had a stroke have visual problems even though only Diplopia from a recent stroke is confusing to the 42% of multidisciplinary stroke team reported patient because adaptation in order to improve visual objective findings of ocular disorders. acuity by a head turn (rotational of the head to the 489 right/left- early stage) or suppression (capacity of the accompany diplopia and may act like a prelude for brain to ignore the information of one eye by the stroke as it stipulates the American Stroke brain- late stage) has not yet occurred. Images may Association guidelines, that is why neuroimaging is appear to overlap each other or may appear adjacent recommended immediately to identify a possible to each other. Diplopia also causes symptoms of concomitant cerebral ischemia (18). There are blurred vision, dizziness, poor balance, alexia, studies (19) which demonstrates that 18.2% of psychological stress, asthenopia, and headaches. patients with retinal ischemia developed a recurrent Sometimes patients cannot recognize double vision stroke after 1 month follow-up. A characteristic sign unless they are asked. for thrombembolic predisposition is the Hollenhorst Double vision can be constant or variable. Binocular plaque (cholesterol plaque)in the retina (20). diplopia may vary depending on the direction of Papilooedema may be present due to the brain gaze or with tilting or turning of the head. Fatigue oedema secondary to stroke. (21). Posterior pole may also contribute to variable double vision. hemorrhages (Terson syndrome) as a result of Most stroke survivors with a known cerebral stroke- intracranial hemorrhages may be present (22). related diplopia have an overwhelming impulse to There are also risk factors which should be explored close one eye or have been instructed to patch the such as: diabetes mellitus, hypertension, deviating eye in order to eliminate the second image. hyperlipidemia, coronary artery disease and tobacco This makes the patient happy for the moment use which can act as a trigger for recurrences of because the patch resolves the diplopia. stroke (12,23). The stroke may be associated with Unfortunately, patching the deviating eye for too visual field deficits. Some authors (24,25) consider many weeks can facilitate the binocular dysfunction that visual field defects indicates a poor clinical and reduce peripheral vision. Stroke-related outcome, risk of falls and mortality in patients with binocular dysfunctions with mild-to-moderate stroke. paretic angles of strabismus are often capable of a wider range of motion of the effected eye. This can Clinical examination be achieved by having the patient monocularly track It is mandatory to follow a complete ocular exam, a moving target (pursuits) in the direction of the including the exam of visual acuity with the best restrictions several times per day for a few weeks. correction, ocular fundus assessment, intraocular Severity of diplopia (mild, moderate, severe) in pressure measurement and refraction examination. different gaze position may be established by the The presence and evaluation of diplopia starts with patients by completing the Diplopia Questionnaire the ocular motility exam by testing ductions in all (freelyavailableat:www.pedig.net )on a 5-pointscale directions of the gaze. The motility is reduced or (always, often, sometimes, rarely, never) (14). absent in the direction of the paretic muscle in a Squint associated with diplopia significantly affects incomitant squint and mostly indicates a neurogenic the patient´s quality of life. Rowe et al in his palsy (26). multicentre observational cohort study revealed that The presence or absence of eye deviation is assessed 16.5% of patients with stroke had squint with by cover/uncover, alternate cover, and/or Maddox diplopia (13). rod testing. The amplitude of deviation can be Diplopia can be associated with vertical gaze in recorded with prisms, using prism cover test and palsies of the third and fourth cranial nerves Maddox rod testing when necessary, in primary (midbrain and thalamic infarcts) and with saccades position at distance (5 m) and near (30 cm) and in all of the eye mediated by the frontal lobes. The cardinal gazes. saccadic defects may appear after both cortical and The prism and alternate cover test alternates the brainstem infarcts (13). Another possible association cover over both eyes while a prism is placed in front of diplopia may be the bidirectional horizontal of one eye. This helps measure the difference nystagmus due to a posteroinferior cerebellar strokes between the two eyes and determine what prism is (15). Unfortunately visual problems after stroke are needed to fix the double vision. under estimated in patients with stroke (16) Hanna et Fusion amplitudes is measured for patients with al. (17) developed a screening tool for visual long-standing deviation, and presence of impairment post stroke.The authors concluded that excyclotorsion is identified by using double Maddox the existing tools gave incomplete evaluation of rod test. visual troubles after stroke (17).Retinal ischemia can 490 eye. Studies reporting data on success of prisms in Nonsurgical treatment in diplopia treating diplopia are limited to a few case series that Nonsurgical treatment in diplopia includes prism lack details of ocular misalignment and prism prescription and botulin toxin injection. prescriptions (35,36,37,38,39). It is generally Prism is a transparent, solid, triangular refracting believed that prism glasses are most successful in medium with a base and apex. Its apical angle eliminating diplopia in patients with comitant determines the power of prism. A prism of one deviations of less than 10–12 prism diopters (PD), prism diopter power (Δ) produces an apparent although the success of prisms for deviations greater displacement of one centimeter to an object situated than 10 PD and for incomitant deviations has not one meter away. Light entering the prism will been systematically studied (35). deviate toward